Pearls of wisdom: Practical application of the Pearls series

Scores of ASHRM members have collaborated to produce the Pearls Series, a set of pocket guides on topics of interest for not only risk managers but also administrators, clinicians, and board members. The succinct format facilitates the dissemination of pertinent information to a wide audience. Risk managers should be knowledgeable of the Pearls topics, understand how to develop appropriate metrics, and manage the monitoring and performance improvement aspects that are critical to ensuring successful knowledge transfer.     

Shoulder Dystocia: Risk Factors and Prevention

Failure of the shoulders to deliver after delivery of the head is known as shoulder dystocia. The risk factors associated with its occurrence were examined in women delivering vaginally at Jordan University Hospital. The profile of the patient most likely to present with shoulder dystocia was determined to be a multiparous, obese patient, over 42 weeks' gestation in a pregnancy complicated by preeclampsia or diabetes with an infant weighing 4,500 g or more. Neonatal complications were noted to be high. There was no maternal death but 4 stillborn infants were delivered and 1 died in the immediate neonatal period.     

Intestinal Surgery in Gynaecological Oncology

Over a 4-year-period, 117 patients had 139 intestinal operations performed in a gynaecological oncology unit. Most of the patients had gynaecological malignancy as the indication for their operation, but 18% had a gastrointestinal primary and 10% had benign pelvic conditions which required intestinal surgery. Most of the patients with malignancy had an ovarian primary cancer. The next most common primary site was the gastrointestinal tract and here carcinoma of the sigmoid colon was the most common. There were 102 large bowel and 36 small bowel operations. Sixteen patients had more than one intestinal procedure. The most common complication of the intestinal operations was prolonged ileus which occurred in 9 instances. Three patients required repeat laparotomy for postoperative bowel obstruction. There were 3 postoperative deaths occurring within 30 days. An assessment of the usefulness of preoperative investigations showed that there was a 10.3% false negative result reported from X-rays, scans or endoscopies. This factor makes it imperative that the surgeon operating on gynaecological malignancy should be capable of dealing with intestinal surgical procedures when required as it is not possible to rely on preoperative investigations to point out those that may require intestinal surgery.     

The role of percutaneous nephrostomy in gynecologic oncology

Percutaneous nephrostomy can provide rapid relief of renal failure due to ureteral obstruction by contiguous spread of cervical malignancy. A series of 26 percutaneous nephrostomies placed in 14 patients with cervical cancer, using only local anesthesia and ultrasound or fluoroscopic guidance is presented. Twelve patients experienced no complications, one developed pyelonephritis which cleared rapidly with antibiotics, and one suffered a hematoma managed by surgical nephrostomy. Three of six previously untreated patients and one of eight patients with recurrent disease survived over a year. A single exenterated patient was stented when anuria developed after surgery to correct a conduit leak. This patient survives at 1.5 years with no evidence of recurrence. Indications for percutaneous nephrostomy, anticipated benefits, and the decision-making process involved in determining who to stent is reviewed.